EXCESS PROFESSIONAL LIABILITY INSURANCE POLICY



| ASPEN AMERICAN INSURANCE COMPANY |BROKERING AGENT’S REGISTER No. __________ [Florida Applicant’s Only] |

| | |[pic] |

| |New Business Application | |

| |Management Liability Package for Private Companies | |

| | | |

| |Directors & Officers and Entity Liability, Employment Practices Liability, Fiduciary | |

| |Liability, Employed Lawyers Liability, Crime and Kidnap Ransom and Extortion Coverage | |

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|NOTICES [INAPPLICABLE TO THE CRIME COVERAGE SECTION AND KIDNAP RANSOM AND EXTORTION COVERAGE SECTION]: THIS IS AN APPLICATION FOR CLAIMS-MADE AND REPORTED INSURANCE|

|PROVIDED THROUGH ASPEN AMERICAN INSURANCE COMPANY. IT IS IMPORTANT THAT THE APPLICANT REPORT ANY CURRENTLY KNOWN CLAIMS OR CIRCUMSTANCES THAT COULD RESULT IN A CLAIM|

|TO THE APPLICANT’S CURRENT INSURER OR PURCHASE AN EXTENDED REPORTING PERIOD ENDORSEMENT TO COVER SUCH CLAIMS OR INCIDENTS. ASPEN AMERICAN INSURANCE COMPANY WILL NOT|

|PROVIDE COVERAGE FOR CLAIMS OR INCIDENTS WHICH THE APPLICANT IS AWARE OF PRIOR TO THE INCEPTION DATE OF ANY COVERAGE THAT IS OFFERED AND ACCEPTED. |

|INSTRUCTIONS FOR COMPLETING APPLICATION: |

|Whenever used in this Application, the term “Applicant” shall mean the parent organization and all subsidiaries, unless otherwise stated. |

|Please type or print clearly in ink. All questions must be answered completely. If any questions are considered “not applicable,” please explain why. If you need |

|more space, continue on a separate sheet and indicate the question number. This Application and all supplemental forms must be signed and dated by an active |

|Principal, Partner, Managing Member or Senior Officer of the Applicant. The original copy of the signed and dated Application is needed before any coverage can be |

|bound. Return this and all supplemental applications to: |

|Aspen American Insurance Company |

|101 Hudson Street |

|Jersey City, NJ 07302 |

|Attn: Management Liability |

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|Please read this entire Application carefully before signing. Whenever used in this application, the term “Applicant” means the parent organization and all |

|subsidiaries, unless otherwise stated. |

|Requested Effective Date: From |

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|To |

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|12:01 a.m. Standard Time at the street address of the Applicant |

PART I: GENERAL APPLICANT INFORMATION

|Name of Applicant: |      |

|Applicant principal information: |

|a. Address: |      |

|City: |      |State: |      |Zip Code: |      |

|Telephone: |      | |

|b. Website: |      |c. Primary SIC Code(s): |      |

|d. State of Incorporation: |      |e. Years of Operation: |      |

|f. Legal Structure (e.g. Corporation, LLC): |      |

|g. Describe nature of the Applicant’s business: |      |

|h. Name of Parent Corporation (if not Applicant): |      |

1. Please list all Subsidiary companies:

|Name of Entity |Nature of Operations |Date Acquired or Created|% of Ownership |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

2. Employee Profile: Total worldwide employee count:       Number of in-house counsel:      

3. Financial Information: Please provide the following information for the Applicant and its Subsidiaries. Information must be based on the most recent fiscal year end audited financials or interim financials (indicate Month/Year). Attach copies of the latest consolidated audited or interim financial statements.

|Requested Information |Current Fiscal Year |Prior Fiscal Year |

|Month/Year |     /      |     /      |

|Total Revenue |      |      |

|Current Assets |      |      |

|Total Assets |      |      |

|Current Liabilities |      |      |

|Long Term Debt |      |      |

|Total Liabilities |      |      |

|Retained Earnings |      |      |

|Shareholder Equity |      |      |

|Net Income |      |      |

|Cash Flow from Operations |      |      |

4. Has the Applicant or any of its Subsidiaries changed auditors in the past year? Yes No

5. Is the Applicant or any of its Subsidiaries involved in any joint ventures, general partnerships or limited partnerships? Yes No

6. Is the Applicant a Public/Governmental Entity, a Tax Exempt/Nonprofit Entity, an organization with Publicly Traded/Issued Securities or an organization subject to Tribal Law? Yes No

7. Has the Applicant in the last 24 months transacted or does the Applicant anticipate in the next 12 months:

a. Any actual, negotiated or attempted merger, acquisition, consolidation or divestment? Yes No

b. Any restructuring or legal or financial reorganization or filing for bankruptcy? Yes No

c. Any branch, location, facility, office or subsidiary closings, consolidations or reductions in workforce? Yes No

8. Does the Applicant perform any professional services for a fee? Yes No

If the Applicant answered “Yes” to any of Questions 6 through 10, please explain:

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PART II: INSURANCE INFORMATION

1. Please provide details on the following insurance coverage currently in place. Indicate by placing an “X” in the box for which coverages are being requested and complete relevant portions of this Application and any applicable Supplemental Applications. The Continuity Date below means the policy inception date for which the most recent main form application was executed.

|Basic Coverage |Coverage Requested|Limit |Current Limit |Current |Current Carrier |Continuity |

| | |Requested | |Retention | |Date |

|Employment Practices | |      |      |      |      |      |

|Fiduciary Liability | |      |      |      |      |      |

|Employed Lawyers | |      |      |      |      |      |

|Crime | |      |      |      |      |      |

|Kidnap Ransom Extortion | |      |      |      |      |      |

2. With respect to the above coverages, has any insurer made any payments, received notice of claim or potential claim, or non-renewed any management liability or similar insurance any time in the last 36 months? Yes No If “Yes”, please attach details.

PART III: DIRECTORS & OFFICERS AND ENTITY LIABILITY INFORMATION (Complete if only filing for this Coverage)

1. Ownership

a. What percentage of voting shares are owned directly or beneficially by Directors and Officers or Board of Managers?      

b. Do any shareholders or group of affiliated shareholders (including an employee stock ownership plan) own five percent (5%) or more of the voting shares directly or beneficially? Yes No If “Yes”, please designate name and percentage of holdings:      

c. Are any of the Applicant’s securities or those of its Subsidiaries publicly traded or the subject of a “shelf registration”? Yes No

d. Is any of the Applicant’s stock held by an Employee Stock Ownership Plan? Yes No

e. Does the Applicant or any of its Subsidiaries have any portion of its debt purchased by the public? Yes No

f. Does the Applicant have any debt or equity interests held by hedge, private equity or venture capital fund(s)? Yes No

2. Is the Applicant currently, or during the past 12 month has the Applicant been, in breach or in violation of any debt covenant? Yes No

3. Has the Applicant experienced changes to its Board of Directors or to its Key Executives over the past year? Yes No If “Yes”, please provide details.

4. Has the Applicant in the past 24 months had, or does the Applicant anticipate in the next 12 months, any private or public offering of debt or equity of securities, including but not limited to such an offering under the Jumpstart Our Business Startups Act (“JOBS Act”)? Yes No If “Yes”, please provide details.

5. Does the Applicant have any of the following Committees? Please check all that apply.

Audit Compensation Nominating

6. Claims Experience and Potential Exposures

a. In the past three (3) years, has the Applicant’s outside auditors noted any material weakness in the Applicant’s internal controls? Yes No

b. In the past three (3) years, has any person or entity proposed for coverage been the subject of, or been involved in, any of the following:

i. Anti-trust, copyright, patent or unfair trade litigation? Yes No

ii. Civil or criminal action or administrative or regulatory proceeding charging or investigating a possible violation of any federal or state securities law or regulation? Yes No

iii. Any other criminal action? Yes No

iv. Representative actions, class actions or derivative suits? Yes No

v. Bankruptcy, receivership or insolvency? Yes No

If “Yes” to any of the above in Question 6, please attach a full description of the details.

PART IV: EMPLOYMENT PRACTICES LIABILITY INFORMATION (Complete only if applying for this Coverage)

1. Workforce Information (responses to encompass Applicant and all Subsidiaries).

a. Breakdown of Employees

|Type of Employee |Current Year |Previous Year |

|Full time Domestic Employees |      |      |

|Part time Domestic Employees (include leased and seasonal) |      |      |

|Number of Domestic Employees located in California |      |      |

|Number of Foreign Employees (Full Time and Part Time) |      |      |

|Number of Independent Contractors |      |      |

b. Percentage of Employees unionized:      %

c. Employee turnover rate: Current Fiscal Year:       Prior Fiscal Year:      

2. U.S. Salary Ranges

|Employee Salary Ranges |% in Range |% of Employees that are Classified as |

| | |Exempt Status under FLSA |

|Less than $60,000 |      |      |

|$60,000 - $120,000 |      |      |

|$120,000 or Greater |      |      |

3. Human Resource Practices and Policies

a. Does the Applicant have a Human Resources or Personnel Department, or designated/qualified staff member(s) serving the equivalent function? Yes No

b. Does the Applicant have a human resources manual or equivalent written management guidelines? Yes No

c. Has Legal Counsel reviewed the human resources guidelines in the last two (2) years? Yes No

d. Does the Applicant have and distribute an employee handbook or guidelines on employee conduct? Yes No

e. Does the Applicant require annual written performance reviews for all employees? Yes No

f. Does the Applicant require background checks in the hiring process? Yes No

g. Does the Applicant maintain a formalized process for employees to report complaints? Yes No

h. Are there written procedures for handling employee grievances, complaints, or complaints of discrimination or sexual harassment? Yes No

i. Has the Applicant implemented and adopted anti-discrimination/harassment policies? Yes No

j. Does the Applicant provide employees with training seminars regarding anti-discrimination/harassment and have all management staff and officers attending training within the last 18 months? Yes No

k. Does the Applicant require all employment issues relating to terminations, discriminations, sexual harassment, layoffs, transfers, or promotions to be reviewed with human resources personnel and either in house or outside counsel? Yes No

4. Anticipated or Actual Reductions in Workforce

a. Is the Applicant currently undergoing or does the Applicant contemplate undergoing during the next twelve (12) months any employee layoffs or early retirements (included ones resulting from any type of company restructuring or office, plant or store closing)? Yes No If “Yes”, please attach complete details.

Please provide the number of layoffs that have occurred or are about to occur:      

b. Have there been any structured layoffs in the past twenty-four (24) months? Yes No

If “Yes”, what percentage of employees? Less than 5% 5-10% 11-25% Over 25%

c. Does the Applicant use outside counsel during lay off procedures? Yes No

d. Does the Applicant have procedures in place to assist terminated or laid off employees find work? Yes No

5. Third Party Liability (complete only if Third Party Wrongful Act Coverage is requested)

a. Does the Applicant have written procedures and policies in place that govern employee behavior when dealing with individuals outside of the company? Yes No

b. Does the Applicant have in place written procedures and policies for the reporting to responsible senior management of complaints of discrimination against, or harassment of, individuals other than employees or applicants for employment? Yes No

c. What percentage of the Applicant’s employees deal with the general public, work at customers’ locations or perform a majority of their functions off site?      %

6. Past Experience

a. During the past three years has any Applicant, in any capacity, been involved in:

i. An EEOC charge or other similar administrative proceeding? Yes No

ii. Any employment-related civil suit or claim (including EEOC charge) resulting in payment (including defense costs) over $10,000? Yes No

iii. Any action or civil suit brought against them by a customer, client or third party alleging harassment, discrimination, or civil rights violations? Yes No

b. Has the Applicant committed any violations of, or paid any claims related to “Wage and Hour” laws? Yes No

If “Yes” to any of the above in Question 6, please attach a full description of the details including date, type of claim, allegations, current status, defense costs incurred and any judgment or settlement amounts.

PART V: FIDUCIARY LIABILITY COVERAGE INFORMATION (Complete only if applying for this Coverage)

1. Plan Information

a. List of Plans for which coverage is requested.

|Plan Name |Plan Assets (current |Number of Plan | |For DB only: Current funded | |

| |year) |Participants |Type of Plan * |% under Pension Protection |Plan |

| | | | |Act? Indicate if “at risk”. |Status** |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

* Type of Plan: Welfare (W); Defined Benefit (DB); Defined Contribution (DC); ESOP (ESOP); Other (O)

** Plan Status: Active (A); Merged (M); Sold (S); Terminated (T); Frozen (F)

b. If any plan for which coverage is requested holds or invests in securities of the Applicant or any Subsidiary or affiliate, please provide details, including name of plan, number of shares held, and most recent share value. If no such securities, check here: None

c. Are any plans NOT in compliance with plan agreements or ERISA? Yes No

d. Are assets managed by an investment manager as defined in ERISA? Yes No

If “No”, or if only some assets are invested by an investment manager as defined in ERISA, please provide details on an attachment.

e. How often is the performance of the plan’s investment managers reviewed? At least semi-annually Less than semi-annually

f. How often do the fiduciaries establish or amend the investment manager’s guidelines and goals for the plans? At least semi-annually Less than semi-annually

g. Does the Applicant follow a written procedure to determine the reasonableness of all plan fees, including revenue sharing arrangements? Yes No

h. Is any plan a multiemployer or multiple employer plan? Yes No

i. Does the Applicant have any non-qualified plans? Yes No

j. In the past twenty four (24) months has there been, or, in the next twelve (12) months is there anticipated, any amendment that has resulted in or is expected to result in any reduction or cessation of benefits or benefit accruals, including but not limited to an increase in participants’ share of costs? Yes No

k. Has any plan (or any portion of a plan) been spun off (sold), transferred or terminated or is any such transaction contemplated? Yes No

l. Are there any overdue employer contributions for any plan, or has any plan requested or contemplated filing a request for a waiver of contribution? Yes No

m. Is any plan a cash balance or pension equity plan, or is any conversion to such plan being considered? Yes No

2. Past Activities

a. In the past three years, has the Applicant merged, terminated or frozen any plan(s)? Yes No

b. Has any fiduciary been accused, found guilty of or held liable for a breach of trust? Yes No

c. Has any fiduciary been convicted of criminal conduct? Yes No

d. Has there been any assessment of fees, fines or penalties under any voluntary compliance resolution program or similar voluntary settlement program administered by the IRS, DOL or other government authority against any plan? Yes No

e. Have any claims (other than for appeals of adverse benefit determinations under 29 C.F.R. § 2560.503-1(h) or similar procedures pursuant to applicable law) been made during the past five years against any Applicant, benefit program, or any past or present individual in his or her capacity as a fiduciary of any employee benefit plan? Yes No

If “Yes” to any of the above in Question 2, please attach a full description of the details.

PART VI: EMPLOYED LAWYERS LIABILITY (Complete only if applying for this Coverage)

1. Breakdown of Total Number of Attorneys

|Type of Attorney |Total Number |Number with More than 10 Years |

| | |Legal Experience |

|Employed Lawyers |      |      |

|Temporary Attorneys |      | |

|Contract Attorneys (not including outside counsel) |      | |

2. Legal Work Performed

a. Do any Employed Lawyers, Temporary Attorneys or Contract Attorneys provide legal services in any of the following practice areas:

i. Environmental Law & Compliance Yes No

ii. Copyright, Patent, Trademark and Other Intellectual Property Law Yes No

iii. Litigation Yes No

iv. Securities Law Yes No

b. Describe the types of legal work typically referred by the Applicant to outside counsel?

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c. Do any Employed Lawyers provide Moonlighting Legal Services? Yes No

If “Yes”, describe the scope of services provided and the total number of hours annually.

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3. Past Experience

Has any person proposed for this coverage been the subject of, or been involved in, any of the following arising out of his or her provision of legal services, irrespective of whether such activity arose out of work performed for the Applicant:

a. Any reprimand, sanction, fine or discipline by, or refused admission to, a bar association, court, administrative or regulatory agency? Yes No

b. Any civil or criminal litigation, arbitration, claim or administrative or regulatory proceeding during the last five years? Yes No

If “Yes” to any of the above in Question 3, please attach a full description of the details.

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PART VII: CRIME COVERAGE INFORMATION (Complete only if applying for this Coverage)

1. Employee and Location Information

| |Number of Locations |Number of Employees |No. of Employees who handle, have access to|

| | | |or maintain records of money, securities or|

| | | |other property |

|United States |      |      |      |

|Outside of United States |      |      |      |

|Total |      |      |      |

List countries outside of United States:      

2. Internal Controls

a. Is there an annual audit or review performed by an independent CPA on the books and accounts, including a complete verification of all securities and bank balances? Yes No

b. Is countersignature of checks required? Yes No

c. Are check signers instructed to require that all checks be accompanied by properly approved vouchers and/or invoices? Yes No

d. Does the Applicant allow the employees who reconcile the monthly bank statements to also sign checks or handle deposits? Yes No

e. How often and by whom are audits of cash and accounts performed?      

f. Does the Applicant have physical inventory? Yes No

If “Yes” to physical inventory:

i. Does Applicant perform a physical inventory check at a minimum of annually? Yes No

ii. Are any quarterly or monthly counts performed? Yes No

iii. Who performs the inventor audit? External CPA or Third Party Internal Personnel

iv. Is inventory protected by physical security such as access controls, security cameras, etc? Yes No

g. Is there a CPA letter to management relating to internal control weaknesses or did the CPA make recommendations for improvement in internal control procedures informally? Yes No If “Yes”, please provide complete details.

h. Does Applicant have an internal audit department? Yes No

i. Please indicate all applicable pre-employment reference checks that the Applicant performs for all its potential employees? Criminal Prior Employment Credit History References Drug Testing

j. Are employee’s building access cards denied immediately upon termination and are all procurement, credit cards, etc. cancelled? Yes No

k. Does the Applicant maintain a list of authorized vendors for all purchases? Yes No

l. Does the Applicant have a procedure to verify the existence and ownership of new vendors prior to adding them to the authorized master vendor list? Yes No

m. Does the Applicant strictly comply with dual recorded authorization for all outgoing electronic funds transfers? Yes No

n. Are computer system access codes and passwords changed at least every 60 days? Yes No

o. Do any non-employees have access to the computer systems? Yes No

p. Does the Applicant have custody or control over any funds, accounts, or materials of any of its clients? Yes No

3. Past Activities

Please attach a list of all employee theft, forgery, computer fraud or other crime losses discovered by the Applicant in the last five years, itemizing each loss separately. Include date of loss, description and total amount of loss; or indicate here if none: None

PART VIII: KIDNAP RANSOM & EXTORTION COVERAGE INFORMATION (Complete only if applying for this Coverage)

1. Risk Profile

Is coverage desired for any of the following: independent contractors, leased or temporary employees, volunteers or students? Yes No If “Yes”, please include these persons in the overall employee account below.

|Country |Number of Employees |Number of Locations|Type of Operation in |Number of Employees |Number of Annual |

| |“Residing” in Country |of Operation in |Country |“Traveling” to Country|Trips/Average Stay for |

| |more than 6 Months |Country | |less than 6 Months per|Employees Traveling to |

| |Cumulative per Year | | |Year |Country |

|      |      |      |      |      |     /      |

|      |      |      |      |      |     /      |

|      |      |      |      |      |     /      |

|      |      |      |      |      |     /      |

|      |      |      |      |      |     /      |

2. Please indicate all that are applicable to Applicant’s operations:

Utilizes the services of a Security Consultant Crisis Management Plan is in Place None

3. Past Activities

a. Has the Applicant or any person(s) to be covered under this policy ever received an actual, attempted or threatened kidnapping, extortion, detention or hijacking attempt? Yes No

b. If “Yes”, please include details itemizing each loss separately.      

PART IX: WARRANTY: PRIOR KNOWLEDGE OF FACTS/CIRCUMSTANCES/SITUATIONS

1. The Applicant must complete the warranty statement below:

• For any Liability Coverage Part for which coverage is requested and is not currently purchased, as indicated in Section II, Insurance Information, of this Application;

• If the Applicant is requested larger limits that are currently purchased, as indicated in Section II, Insurance Information, of this Application.

The statement applies to those coverage types for which no coverage is currently maintained; and any larger limits of liability requested.

For Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Kansas, Kentucky, Maine, Massachusetts, Missouri, Nebraska, New Hampshire, Nevada, North Carolina, Oklahoma, Oregon, Pennsylvania, South Dakota, Virginia, Washington, West Virginia and Wyoming Residents ONLY: the title of this section and any other reference to “Warranty” is deleted and replaced with “Applicant Representation”.

Statement: No person or entity for coverage is aware of any fact, circumstance, or situation which he or she has reason to suppose might give rise to a claim that would fall within the scope of the proposed Liability Coverage Part(s):

NONE, OR EXCEPT as outlined below:

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NOTICE: Without prejudice to any other rights and remedies of Aspen American Insurance Company (hereinafter “Insurer”), the Applicant understands and agrees that if any such fact, circumstance or situation exists, whether or not disclosed above in response to Question 1 above, any claim or action arising from such fact, circumstance, or situation is excluded under any policy issued by the Insurer. Report all known claims and/or circumstances to the Applicant firm’s current insurer.

PLEASE PROVIDE ADDITIONAL COMMENTS THAT WOULD FURTHER CLARIFY THE INFORMATION ABOVE OR ADDRESS CHARACTERISTICS OF THE APPLICANT FIRM’S PRACTICE NOT SPECIFICALLY ADDRESSED HEREIN.

FRAUD WARNING STATEMENT

Notice to Applicants of all states except Colorado, DISTRICT OF COLUMBIA, FLORIDA, kansas, KENTUCKY, Louisiana, Maine, NEW JERSEY, new mexico, New York, OHIO, OKLAHOMA, OREGON, Pennsylvania, tennessee, VERMONT, virginia, washington: Any person who knowingly, and with the intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any material false information or conceals for the purposes of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties and denial of insurance benefits.

Notice to Colorado Applicants: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the department of regulatory agencies.

Notice to DISTRICT OF COLUMBIA Applicants: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if

false information materially related to a claim was provided by the applicant.

Notice to FLORIDA Applicants: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

NOTICE TO KANSAS APPLICANTS: any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy, or a claim for payment or other benefit pursuant to an insurance policy which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a crime and subjects the person to criminal and civil penalties and denial of insurance benefits.

Notice to kentucky Applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material

thereto commits a fraudulent insurance act, which is a crime.

Notice to Louisiana Applicants: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Notice to Maine and washington Applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

Notice to new jersey Applicants: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Notice to new mexico Applicants: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

Notice to New York Applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Notice to OHIO Applicants: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Notice to OKLAHOMA Applicants: Warning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer or makes a claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Notice to OREGON Applicants: Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an application, or (2) by filing a claim containing a false statement as to any material fact, may be violating state law.

Notice to Pennsylvania Applicants: Any person who knowingly, and with the intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any material false information or conceals for the purposes of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.

Notice to tennessee and virginia Applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

NOTICE TO VERMONT APPLICANTS: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

This application is in compliance with Section 626.752, Florida Statutes. A copy has been furnished to the applicant or insured and coverage is: [ ] Bound Effective (time) (date); [ ] Not Bound.

Broker’s Signature:

Some states require that we have the Name and Address of your (Applicant’s) Authorized Agent or Broker.

Signature of Authorized Agent or Broker: ___________________________________________________________

Name of Authorized Agent Broker: _________________________________________________________________

Address:_____________________________________________________________________________________

License Identification Number: [Florida Applicant’s Only] _____________________________________________

By signing this Application, the undersigned, on behalf of the Applicant and all insureds proposed for coverage, represents and agrees to each of the following five (5) items:

1. The Applicant firm has made a comprehensive internal inquiry or investigation to determine whether any Applicant firm member is aware of any act, error, omission, personal injury, fact, circumstance, situation or incident which could be a basis for a claim or suit under the proposed insurance;

2. This Application, and any required additional supplemental applications submitted to and accepted by the Insurer shall constitute the Application;

3. Each of the statements and answers given in this Application, and in each of the supplemental applications are:

a. Accurate, true and complete to the best of the Applicant’s knowledge;

b. No material facts have been suppressed or misstated;

c. Representations the Applicant firm is making on behalf of all persons and entities proposed to be insured;

d. A material inducement to the Insurer to provide insurance, and any policy issued by the Insurer is issued in specific reliance upon these representations.

4. This Application, along with each of the supplemental applications are hereby deemed to be attached to, and incorporated into, any policy contract that is issued, regardless of whether the Application or any of the supplemental applications are signed or dated; and

5. The Applicant agrees to promptly report to the Insurer, in writing, any material change in its operations, conditions, or answers provided in this Application, or any supplemental applications, that may occur or be discovered between the date of completion of such Application(s) and the inception date of any policy issued by the Insurer. Upon receipt of any such written notice, the Insurer has the right, at its sole discretion, to modify or withdraw any proposal for insurance, including any bound coverage.

This Application must be signed and dated by a Principal, Partner, Managing Member or Senior Officer of the Applicant. Electronically reproduced signatures will be treated as original.

I understand this application is not a binder unless indicated as such on this form by the brokering agent.

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